Higher, Tighter Skin – Lifted onto Pegs

Some plastic surgeons are using the Endotine, a new device for people who want only a more understated rejuvenation that removes seven to ten years. The device is a small, biodegradable implant affixed to bone or other very stable structures deep under the skin. Muscles and skin of the face are lifted higher and suspended on the Endotine. Given time, the tissues affix themselves to bone in the new, higher position.

Competitive body builder and gym owner Patti Kilroy, 49, has stayed in championship form for two decades with one slight exception: her face. So she wanted just a little something from her cosmetic surgeon to correct some facial sagging, making her look less tired and more alert. However, Patti did not want a full, appearance-changing surgical facelift.

“I’ve had friends who went off on ‘vacation’ and returned a week later looking unbelievably rested and refreshed,” Patti says. “That was the look I wanted from cosmetic surgery.”

“Quick Fix” Surgeries

Nonetheless, it took three years -- with trips to Texas and Florida – to search and find a surgeon with whom Patti felt comfortable. Eventually, she interviewed Mark Beaty, M.D., in her home town, Alpharetta, Georgia.
Patti’s search is part of the largest trend sweeping plastic and cosmetic surgery – the desire for quick, less invasive cosmetic procedures that require no anesthesia. According to the American Society for Aesthetic Plastic Surgery, the use of quick fix surgeries has increased 764 percent since 1997, six and one-half times faster than more invasive cosmetic plastic surgery.

During her initial consultation, Patti listened carefully as Dr. Beaty explained how a midface lift with something known as an Endotine fixation device could take perhaps a decade off her appearance. Both foreheads, upper eyelids and mid-faces are lifted with the fixation implant.

An Endotine actually lifts skin by being surgically attached to bone. The device has anywhere from three to five pegs, or tines, on which the surgeon places the lifted tissues after the doctor has loosened the flesh from its old position. Eventually, the muscle and skin grow back to bone in the higher position while the Endotine itself dissolves. Patti opted to go forward with the procedure which is often known as a young person’s facelift because the typical patient is usually under 40 and not ready for an extensive surgical procedure.

“My only concerns were about the implant dissolving and giving up my once-a-month facial for a while,” Patti says. “I also had to give up exercise for three and a half weeks. For a while, I could feel a little bump where the device was implanted under my scalp.”
According to Dr. Beaty, after an Endotine procedure, patients must avoid jostling their faces too much or washing their hair too vigorously – least they jar loose the lifted facial tissues -- during healing.

To start, Dr. Beaty placed the Endotine on her skull behind the hairline, gingerly separated the facial tissues away from bone, pulled up skin, muscle and other tissues and firmly transfixed them onto the teeth of the Endotine. Coapt, the Palo Alto, California, firm that has made the Endotine since 2002, calls the multiple tine fixation devices “Multi-Point Technology.”
“Surgeons work close to some very important facial nerves and vessels in the face so they must know facial anatomy like the back of their own hands,” says Dr. Beaty.

The cheek lift improves wrinkled, sagging and aging tissues of the mid-face, the area between your lower eyelids and your mouth. The brow lift removes a worried, wrinkled forehead and, in some cases, can make the eyes look more open by lifting the eyelids.
Surgeons can now place an Endotine on the cheek bone through the mouth, the lower eyelid or through a small incision above the ear. If one side of the face is still out of balance, the surgeon can easily pick up the tissues and make adjustments. The procedure can be done with a local or general anesthesia. Experts say Endotines can also make any woman prettier by sculpting the cheeks into a higher position. That, in turn, gives her whole face more of a classic heart shape. Some know the structure as a “beauty trench;” which is an S-curve that starts at the upper cheek, folds back under the lower cheek and ends at the jawline. Some midface Endotine lifts can also lift the lines at the corner of the patiente’s mouth.

Says Patti: “When I went back to the gym, the bruising was gone so I looked refreshed and rested, which was exactly the look I wanted.”

Suspend Sagging Tissues

Endotine fixation devices are neatly dodging a problem plastic and cosmetic surgeons have had for decades. Before, physicians used sutures to pull up and suspend sagging midface tissues. The stitches lifted aging flesh O.K. but had too many undesirable side effects. Nerve entrapment, dimpling of facial skin, longer operating times and no way for the surgeon to easily adjust the placement of the tissues after closing often ensued. But the worst unintended consequence was the thin suture tearing through tissues because it supported too much weight. And that undid the whole procedure.

But now, the Endotine dissolves within six months to a year, and that means less work for the surgeon – and less expense to the patient. Of course, to perform an forehead lift, a surgeon can still opt to use the open surgical method in which the incision starts over one ear and continues over the top of the head to the opposite ear. Normal side effects of that operation include itching and temporary scalp numbness along with a much longer recovery period.

After an Endotine is implanted to lift the forehead, the patient will likely have some swelling and bruising around the eyebrows and forehead which could last as long as ten days. Dressing and drain tubes, if any, are usually removed a few days after surgery. Patients can wash their hair several days afterwards. Recovery is usually completed in less than two weeks although it may require two months for final results to appear, according to Coapt’s website.

Besides placing the Endotine through the mouth – to avoid tell-tale scars on the face – many surgeons opt to use an endoscope, a tube-like device the thickness of a pencil with two, or sometimes three, arms. Inserted through one or half-inch incisions, one arm of the endoscope bears a bright light so the surgeon can see under the skin. The other arm uses small tools that cut and stitch. With some endoscopes, the surgeon looks into an eyepiece; in others, he or she is able to get under your skin and finds his way by watching the tools move on a television monitor.

“Most Endotine implants require a tiny hole drilled into bone with equally tiny screws that hold the device in place,” says N.D. Moscoe, M.D. a plastic and reconstructive surgeon in Austin, Texas. When a brow lift is done, the surgeon drills tiny (4 mm, or 1/8th inch) posts in the skull to hold the Endotine Forehead fixation plate in place.

Feel Endotines

One of Dr. Moscoe’s patients, a Lone Star business owner and plastic surgery patient, who asked only to be identified as a “Lady in Texas” says she celebrated her sixth decade after having an Endotine brow lift.
“I just had to be careful for six weeks and give up the exfoliaters, cleaners and creams I normally rub on my face,” she says.
Mary Orr, 51, an I.B.M. marketing technology specialist in Georgia, received an Endotine eyebrow lift from Atlanta plastic surgeon Amy Simon, M.D.

“After the brow lift, I looked more awake,” Mary says. “My eyes had started to hood over but the procedure took care of that.”
Mary also had a few other procedures, including rejuvenating her lower eyelids, a rhinoplasty, a tummy tuck and a gluteal lift. Most people now think she is in her early 40s, she says.
“The only thing I noticed was that I could feel the Endotines under my scalp when I washed my hair,” says Mary. “But they disappeared in about ten months.”

According to Dr. Simon, most prospective patients have not heard about the various uses for Endotines.
“Surgeons experienced in endoscopic techniques know exactly where they are going through the facial planes and muscles,” says Dr. Simon. “After the tissues have been repositioned upwards, healing starts immediately and that holds the lifted tissues in place. So for the first month or so, we strongly advise patients to avoid pulling on their scalp. The new lift could be dislodged.”
Adds Wendy Lewis, the international beauty expert and plastic surgery coach who advises prospective patients about plastic and cosmetic surgery providers in the U.S., London and Paris: “Endotine fixation devices really don’t have any competition.”
Prospective patients who might want to reconsider the procedure are those with very thin bones, thin scalps, known allergies or foreign body sensitivities to plastic biomaterial. People with very heavy brows may also not be good candidates for a brow lift via Endotine.

Rapidly aging Baby Boomers – that’s everybody born between 1946 and 1964 – are affecting the fields of plastic and cosmetic surgery because they want more quick, in-and-out procedures that require no general anesthesia. Boomers also want their rejuvenation surgery done via the least possible invasive methods. So more under-the skin fixation plates are being offered. Thus, the newest Endotines can be attached to bone without the help of an endoscope. That equipment can be an expensive acquisition for your surgeon which is reflected in your fees for surgery.

Single Incision

One Endotine system slips in through the lower eyelid to lift your cheek area while another can be inserted from the side of your head, just under the temple, for lifting the midface. Both have long tails that allow the surgeon to make quick adjustments for balance and symmetry. Yet another use approved for surgeons is the Endotine TransBleph, an implant that Coapt Systems says allows surgeons to perform brow lifts and upper eyelid rejuvenation at the same time through a single incision in an upper eyelid. Moreover, that procedure also requires only local anesthesia with no endoscope.

Beverly Hills plastic surgeon Toby Mayer, M.D., makes an incision within one of the patient’s crows’ feet, attaches the Endotine to the cheek bone and then pulls the sagging tissues up, essentially lifting from the inside out. Patients typically go home the same day and discard any surgical dressings soon after surgery. The company says swelling is lessened because the operation goes quickly in experienced hands.

Another twist on the same technology sitting on the medical horizon promises to cure a troublesome but common hand and wrist woe. After trauma and other accidents, the flexor tendons in the hand are often damaged and won’t close the fingers. A remedy now under F.D.A. study is bringing the two tendons together with an Endotine device and may be introduced as soon as 2007, according to a company spokesperson.

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